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Insurance Hell All insurance-related matters are here: Medicare, worker's compensation, appeals, denials, insights, wins, losses. PRICING is here too. Note: This forum has posts from 2006 forward. Older ones are in the Big File.


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  #1  
Old 12-14-2015, 08:08 AM
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Romakis Romakis is offline
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Default Optima - Denied

Just got the letter back from my insurance company: Denied.

Denial codes: "D84F - Not medically necessary per Medical Director - Member responsible."

"The requested service is considered investigational and not medically necessary per Optima Policy Surgical 78".

What a surprise...
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  #2  
Old 12-14-2015, 04:01 PM
Stonewall_Boris Stonewall_Boris is offline
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Are you going to appeal?
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Old 12-15-2015, 06:08 PM
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Harrison Harrison is offline
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Romakis,

This may or may not help...see attached. Make the calls / letters anyway. It's a small effort that have a big ROI.
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Medical Hack.jpg  
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Old 12-16-2015, 09:38 AM
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Romakis Romakis is offline
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Default Appeal

Yes, I am going to try to appeal. Thanks Harrison.
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  #5  
Old 12-16-2015, 04:21 PM
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Romakis Romakis is offline
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Default Help

If anyone has any documentation to help me file an appeal, I would highly appreciate it. Please let me know and I will give you my e-mail address. Thank you all in advance!
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  #6  
Old 12-17-2015, 09:05 AM
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Romakis Romakis is offline
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Default

Quote:
Originally Posted by Harrison View Post
Romakis,

This may or may not help...see attached. Make the calls / letters anyway. It's a small effort that have a big ROI.
I called my insurance yesterday, and after 30 minutes of run around they gave me a name of the doctor who accessed my claim and made denial recommendation. I googled this doctor's name and this is what I found:

"Dr. Peggy Ebinger, MD is a psychiatrist in Virginia Beach, Virginia."

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  #7  
Old 02-17-2016, 01:32 PM
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Romakis Romakis is offline
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Default My appeal package

Sending the documentation today. Thank you all who helped me put it together (Jerry, Andi, thank you so much!!!).

Had a hard time finding an envelope to fit all the paperwork...
Attached Thumbnails
appeal.jpg  
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  #8  
Old 02-21-2016, 07:06 AM
JinSong JinSong is offline
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Wow, so the person making the decision was a freaking psychiatrist?! I'm entering into my own ADR denial hell, so this is good information to have.
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Old 05-05-2016, 09:08 AM
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Romakis Romakis is offline
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Default Appeal is also denied

As I expected, the appeal was denied as well by Optima Health. They stated that it was not "medically necessary", and that discectomy should have been used instead .

I guess I should have cut the rest of my discs out, and leave everything else as is .

Man, my appeal was so thick and looked so good ...
Attached Files
File Type: pdf 20160505075944526.pdf (167.6 KB, 19 views)
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Old 05-05-2016, 12:26 PM
Disc replacement 2015 Disc replacement 2015 is offline
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Thumbs down

That really sucks!!! Sorry to hear...
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